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HUMAN ERROR IN FLIGHT

Don Harris

Abstract


In 80% of accidents human error is one of the main causal factors. However, pilot error is not easy to de- fi ne. This paper looks at various ideas of what constitutes human error on the fl ight deck and critically examines some current models of error with respect to modern fl ight operations. The paper then looks at some methods by which error may be eliminated or managed before concluding with a contrasting view of fl ight safety, which rejects the simple idea of error and suggests that most accidents are the product of normal (but uncontrolled) working practices.

References


Civil Aviation Authority, Global Fatal Accident Review 1997-2006 (CAP 776). London: Civil Aviation Authority; 2008.

Dekker SWA. The Re-Invention of Human Error. Hum Factors Aerospace Saf, 2001;1(3): 247-266.

Ruffell Smith HP. A Simulator Study of the Interaction of Pilot Workload with Errors, Vigilance, and Decisions. NASA Technical Memorandum 78482. Moffett Field, CA: NASA Ames Research Center; 1979.

Thomas MJW. Improving Organisational Safety through the Integrated Evaluation of Operational and Training Performance: An Adaptation on the Line Operations Safety Audit (LOSA) Methodology. Hum Factors Aerospace Saf, 2003;3(1): 25-45.

Hollnagel E. Cognitive Reliability and Error Analysis Method: CREAM. Oxford, Elsevier Science, 1998.

National Transportation Safety Board. In-Flight Separation of Vertical Stabilizer American Airlines Flight 587 Airbus Industrie A300-605R, N14053 Belle Harbor, New York November 12, 2001 (NTSB/AAR-04/04). Washington, DC: National Transportation Safety Board; 2004.

Reason JT. Managing the Risks of Organizational Accidents. Aldershot: Ashgate; 1997.

International Civil Aviation Organization. Safety Management Manual, 2nd Edition (ICAO Doc 9859). Montreal: ICAO; 2009.

Reason JT. Generic Error-Modelling System (GEMS): A Cognitive Framework for Locating Human Error Forms. In, Rasmussen J, Duncan K, Leplat J, Eds New Technology and Human Error. London: Wiley, 1987.

National Transportation Safety Board. Aircraft Accident Report: American Airlines Inc. DC 10-10 N110AA; Chicago O'Hare International Airport, Chicago, IL, May 25, 1979 (NTSB/AAR-79/17). Washington, DC: National Transportation Safety Board; 1979.

US Department of Defense. Military Standard: System Safety Program Requirements (MIL-STD-882C). Washington, DC: US Department of Defense; 1993.

Harris D. An Open Systems Approach to Safety Culture: Actions, Influences and Concerns. Australian Aviation Psychology Association (AAvPA) International Conference - Evolving System Safety 2006. Sydney, Australia 9-12 November; 2006.

Bundesstelle fur Flugundfalluntersuchung (2004). Investigation Report AX001-1-2/02. Braunschweig: Author; 2004.

Helmreich RL, Klinect JR, Wilhelm JA. Models of Threat, Error, and CRM in Flight Operations. In, Jensen RS. Ed. Proceedings of the Tenth International Symposium on Aviation Psychology Columbus, OH: The Ohio State University, 1999, 677-682.

European Aviation Safety Agency. Certification Specifications for Large Aeroplanes (CS- 25): Amendment 7. Cologne: EASA. Available from http://www.easa.europa.eu/ws prod/g/rg certspecs.php#CS-25).

Federal Aviation Administration. Report on the Interfaces between Flightcrews and Modern Flight Deck Systems. Washington, DC: US Department of Transportation; 1996.

Embrey DE. SHERPA: A Systematic Human Error Reduction and Prediction Approach. Paper presented at the International Meeting on Advances in Nuclear Power Systems, Knoxville, Tennessee; 1986.

Stanton NA, Harris D, Salmon P, Demagalski JM, Marshall A, Young MS, Dekker SWA, Waldmann T. Predicting Design Induced Pilot Error using HET (Human Error Template) - A New Formal Human Error Identification Method for Flight Decks. Aeronautical J, 2006; 110(2): 107-115.

Harris D, Stanton A, Marshall A, Young MS, Demagalski JM, Salmon P. Using SHERPA to Predict Design-Induced Error on the Flight Deck. Aerospace Science and Technology, 2005; 9(6): 525-532.

Li WC, Hsu YL, Chang D, Wang T, Harris D. Formal Error Prediction: The Evaluation of Standard Operating Procedures in a Large Commercial Transport Aircraft. 13th Air Transport Research Society (ATRS) World Conference. Abu Dhabi, UAE, 27-30 June; 2009.

Li WC, Harris D, Hsu YL, Li LW. The Application of Human Error Template (HET) for Redesigning Standard Operational Procedures in Aviation Operations. In, Harris D, Ed. Engineering Psychology and Cognitive Ergonomics - EPCE 2009 (LNAI 5639). Berlin: Springer-Verlag, 2009.

Dekker SWA. Why We Need New Accident Models. Hum Factors Aerospace Saf, 2004; 3(1): 1-18.

Woods DD, Johannesen LJ, Cook RI, Sarter NB. Behind Human Error: Cognitive Systems, Computers and Hindsight. CSERIAC Gateway, 5. Columbus, OH: CSERIAC; 1994.

Dekker SWA. Drift Into Failure. Aldershot: Ashgate; 2011.

Bennett SA, Shaw AP. Incidents and accidents On the Ramp: Does 'Risk Communication' Provide a Solution? Hum Factors Aerospace Saf, 2003; 3(4): 333-352.

Hollnagel E. FRAM: The Functional Resonance Analysis Method. Aldershot: Ashgate; 2012.

Helmreich RL, Merritt AC, Wilhelm JA. The Evolution of Crew Resource Management Training in Commercial Aviation. Int J Aviat Psychol, 1999; 9(1): 19-32.

Federal Aviation Administration. Line Operations Safety Audits (AC 120-90). Washington, DC: US Department of Transportation; 2006.


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